Wednesday, April 25, 2012

"...so I really think we should try that experimental treatment I read about on the Internet."

"Sorry, patient, we don't do that treatment here. And we don't think it's effective. So that's not going to be part of the plan. Sorry."

"...but I really want it."

"Not here, not from us. Sorry."

TUESDAY...

"...so, I was hoping you'd thought more about that experimental treatment we talked about."

"Nope. Like we said yesterday, not part of what we do here. You're free to go elsewhere for your treatment if you'd like, but we don't do the experimental treatment, and we don't recommend you seek it out, because we don't believe it will positively impact your chances of recovery. But it's up to you. We're happy to let you go elsewhere."

"...but I want to stay here, and get that treatment."

"That's not going to happen, I'm sorry."

WEDNESDAY...

"...so I know we talked yesterday about plans for that experimental treatment."

"Nope, we did not. Not happening here. Sorry."

"...I thought the other doctor said we could explore it."

"Nope, there is no other doctor. You only spoke to us, and we said we're not doing that."

"...I really thought we said we were going to try it."

"We did not say that. Sorry. We never said that."

"...I'm only staying here to get that experimental treatment."

"Then you should go. Because we don't do that treatment. We're happy to release you to go elsewhere for your care."

"...no, I'd rather just stay here, and do that treatment here, like we talked about."

"We did not talk about that, sorry. Not happening, no matter how many times you mention it."

Monday, April 23, 2012

"I have this pain in my chest. When I breathe. I think I need an MRI."

"And how long have you had this pain."

"Ten years. When can I get the MRI?"

"You don't need an MRI."

"How are you going to figure out if the pain is dangerous."

"If the pain was dangerous, you'd be dead by now."

"That's not funny."

"I didn't mean it to be funny. You've had it for ten years. Anything that's going to kill you would have already killed you. Dangerous pain doesn't stick around for ten years. Especially dangerous pain that doesn't seem to interfere with any of your normal activities."

Saturday, April 21, 2012

I'm not saying that people can't be happy-- that I can't be happy-- because I can be, and I often am, and I know people who are, often or even just about always.

But it's hard to be around illness all day. Hopelessness. Poor prognoses. Death. Sadness. Pain. You get used to it, and in some ways that's a good thing, because if you didn't get used to it, you wouldn't be able to get anything done. But in some ways, it's a bad thing, because you start to see the world through that lens, and you forget that there are lots of people out there who aren't sick, who aren't sad, who aren't in the hospital. That there are lots of people out there living their lives and enjoying them, and not waiting for the next shoe to drop. People who aren't professional patients. People who aren't just biding their time until their diagnoses come to get them.

Yes, we will all die, and most of us will get sick before then. It is inevitable. And that's why it's hard to talk yourself out of thinking about it. It's not accurate to say it may not happen to you, because it will happen to everyone. It's not accurate to say you can prevent it. You can try and live a healthy life, and act responsibly, see doctors, get screenings, live carefully... but you're still only tweaking the odds a little bit. Healthy, responsible people get terrible illnesses too. Things that they did nothing to bring on. People die young. People die old. People die. And even people who don't die often live in pain and with disabilities, limitations, and struggles.

Everyone has struggles, whether health-related or not. Everyone has worries, everyone has problems, everyone has their own issues they're forced to deal with. Even people who seem to have it all, from the outside, usually don't.

And it's so easy to dwell on that side of things, to reduce it all to pointlessness. What's the difference, if we're all going to die? What's the point if you can't control your fate, and you could be struck down at any moment? Why even try if any happiness you achieve might all be taken away?

But where does all of that get you, if, at least right now, you're okay? Intellectually, I know it gets me nowhere. I know that happiness is possible, that life can be satisfying and rewarding, that relationships can be satisfying and rewarding, that the day to day can be satisfying and rewarding.

Not everyone loves what they do, but some people do. Not everyone has a rich, full existence, filled with friends they care about and who care about them, activities that bring them joy, families, things to look forward to, meaning-- but some people do. Not every day can be perfect-- every day isn't perfect for anyone. Not every day can be happy, not every moment can be filled with something worth filling it with, but that doesn't mean none of them can.

There are days I don't remember what about this path was supposed to bring me joy, what about this path was supposed to motivate me to be excited to wake up in the morning. I hate those days. I hate the way those days make me feel, about myself and about my life. But I'm also tired of feeling guilty for having those days. I'm tired of feeling guilty or ashamed for feeling sad, for feeling like I'm failing if I succumb to those kinds of thoughts sometimes. Because it's not every day, and it's not every moment, and there is happiness, and there is joy.

I just wish it was easier to grab it sometimes. Easier to remember how to grab it when I most want to find it.

It sounds silly, but I've thought about writing down the things that make me happy. In the moment, the things that make me smile, that make me feel good about the world and about the path I'm on. So I can look at that list when I need to, and remember that sometimes all it takes is a cookie to feel okay about the world. Or an e-mail from a friend. Or crossing something off the to-do list. It's not big things. It doesn't need to be big things. It's small things. And I think it's just when eight, nine, twelve hours pass without any of those small things that the whole world starts to look a little bleaker than I'd like.

I know a lot of people have disappointment, and don't get the positive feedback they're craving. I know a lot of people suffer a heck of a lot more than I ever have. I know I have control over my own life and what I spend my time doing and how I feel about it. I'm just saying that sometimes, when everyone around you will be lucky to make it through the month, it's hard to remember that life can be about more than the road to eventual suffering.

Thursday, April 19, 2012

In fact-- we've been promised CUPCAKES if our team gets the most patients discharged before 11AM.

(This is not sufficient incentive to do anything, by the way.)

See, the hospital wants patients out early so they can get as many new patients admitted as early as possible, to start making money on them. Patients about to be discharged don't have procedures the day of discharge, so there's no money to make. Earlier they leave, the better.

But as soon as someone like me discharges a patient, we have room to get a new one-- and the last thing we want is to get four or five or six new patients in a day, and have to deal with all of those admissions notes.

So, in a perfect world, from my point of view, I want to discharge my patients late in the day, so there isn't time for me to get new ones. Since I'm not allowed to be given new admissions after 4:00 (they go to a different service), my goal is to keep all of my patients until 4:00, and then discharge them afterwards.

Of course, then I end up getting overnight admissions... which still take time the next morning... but not as much time, because someone has done some of the work for me overnight.

If the hospital wanted to align incentives, perhaps they could pass along some of the money they would gain along to residents like me... you want to pay me $200 for everyone I discharge before 11AM, suddenly you would see a lot more early discharges. $100, even. Maybe $75.

But for a chance at cupcakes? No thanks. I'll buy a cupcake if I want a cupcake.

(But I won't buy it from the kiosk in the lobby, because the kiosk in the lobby just got closed by the health department. Would you feel comfortable being a patient in a hospital that can't keep its lobby kiosk sanitary enough to remain open? Hint: YOU SHOULDN'T.)

Tuesday, April 17, 2012

"Um, you should really see a dentist. To be honest, they don't teach us much about teeth in medical school. So you should really see a dentist."

"Oh, but can you look?"

"I guess I can look in your mouth, but, really, a dentist is the person to go to. I can see if there's anything that looks like you need to see a specialist, anything medical that looks like it's going on, but any problems with your teeth, please, please, make an appointment with a dentist, or we can set you up with the dental clinic."

"Oh, but they really hurt."

"Okay, I can take a quick look and see if it seems like there's an obvious infection or something that even I can see is wrong."

She opens her mouth.

And pulls out a complete pair of dentures.

Uppers and lowers.

And tries to put them in my hand.

"Okay, this is definitely an issue for a dentist. I'm really sorry, they don't teach us dentures. I'll give you the number for the dental clinic."

Tuesday, April 10, 2012

Spent over an hour with a patient today. Went through the list of her problems, came up with a medication plan, set out a list of tests she needs to come back for, specialists for her to visit, a comprehensive plan to address her issues... felt like a successful visit... until the very end, when I handed her the prescriptions for the medications, and the slips to take to get the tests she needs... "So you'll do all of this and I'll see you back here in two weeks?"

"Oh, no, I can't come back in two weeks."

"Okay... when can you come back?"

"Never. I'm moving to Siberia [not Siberia, but may as well be] next Monday."

"So you're not even going to be able to get these tests done by then..."

"No, no time."

"And the refills on the prescriptions... you're going to have to go to another doctor, in Siberia, because these won't work halfway across the world..."

"Sure, yeah. I mean, not right away, but I'll try to find someone."

"So this whole visit was just sort of an exercise, in a way, because you can't actually follow this plan we just put together..."

"Yes."

"Why didn't you tell me you were moving to Siberia?"

"I didn't think it mattered."

"Well, bring a medication list, and try and see a doctor there. Good luck."

Monday, April 9, 2012

Patient comes into clinic. Has a medication list (AMAZING). Is on a mess of medications. A mess. Three pills for the same problem, nothing for another problem, two that interact, at least three he shouldn't be on, a couple that should be replaced with better alternatives. So I talk to my attending and we decide to clean up the med list, get him on the right set of pills... and he asks the very legitimate question: WHY SO MANY CHANGES?

And the very legitimate follow-up-- "Did my last doctor screw up?"

Now, fortunately, there doesn't seem to be anything bad that happened because of the less-than-optimal medication regimen. So, fortunately, his questioning is more out of curiosity than any real demand for answers.

It's true that I don't even know if I have an answer for him. I don't know if he's taking the medications he was told to take, and only the ones he was told to take. I don't know if he brought his full med list to his last visit. I don't know if he's still ordering refills on things he should have stopped, until the refills on the prescriptions run out. I don't know if he might have described different symptoms in the past. I don't know if other doctors know more than I do or have had different experiences with different medications.

But I do have a strong feeling that, yes, someone probably screwed up, or at least failed to think about the full medication list. So do you tell that to the patient, or do you glide past the question, and decide that since you don't know for sure, and there don't seem to be any repercussions, the more responsible thing to do is to not throw another doctor under the bus?